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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 4  |  Page : 173-179

Pre-operative evaluation in geriatric patients: Are we over-investigating?


Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission27-May-2022
Date of Decision20-Jul-2022
Date of Acceptance02-Aug-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Dr. Bimla Sharma
Institute of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_44_22

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  Abstract 


The population of the United States, as well as developing countries like India, is rapidly ageing. Surgical operations are more common in the elderly than in younger age groups. A comprehensive pre-operative evaluation of these elderly patients is an important component of improving perioperative outcomes. It is very different from the pre-operative assessment in younger patients, which usually encompasses evaluating cardiac risk for non-cardiac surgery and single end-organ functional assessment. Functional and cognitive impairment are additional risk factors associated with poorer outcomes in older patients. Guidelines for pre-operative assessment of elderly surgical patients have been developed by the American College of Surgeons and the American Geriatrics Society.

Keywords: Frailty and surgery, nutrition status, post-operative outcome, pre-operative assessment, surgery (hip or general)


How to cite this article:
Sharma B, Sahai C, Sood J. Pre-operative evaluation in geriatric patients: Are we over-investigating?. Curr Med Res Pract 2022;12:173-9

How to cite this URL:
Sharma B, Sahai C, Sood J. Pre-operative evaluation in geriatric patients: Are we over-investigating?. Curr Med Res Pract [serial online] 2022 [cited 2022 Sep 27];12:173-9. Available from: http://www.cmrpjournal.org/text.asp?2022/12/4/173/355203




  Introduction Top


The population of the United States, as well as developing countries like India, is rapidly ageing. By 2050, people aged 60 or above will have doubled.[1] Surgical operations are more common in the elderly than in younger age groups. Approximately one-third of surgical patients are over the age of 65 years. When the elderly undergo surgery, they are more likely to have additional illnesses, have reduced physiologic reserve or a combination of these factors.[2],[3] Geriatric specialists will be able to perform more in-depth examinations and accompanying rehabilitative procedures. In order to facilitate post-operative rehabilitation and social reintegration, anaesthesiologists should also be aware of their involvement in patient preparation and enhancement of functional reserve.

A comprehensive pre-operative evaluation of these elderly patients is critical for improving perioperative outcomes. It is very different from the pre-operative assessment in the younger patients, which usually encompasses evaluating cardiac risk for non-cardiac surgery and single end-organ functional assessment. Functional and cognitive impairment are additional risk factors associated with poorer outcomes in older patients.[4],[5] Guidelines for pre-operative assessment of elderly surgical patients have been developed by the American College of Surgeons (ACSs) and the American Geriatrics Society (AGS).[6],[7]


  Methods Top


Data sources and relevant articles were identified using electronic databases (PubMed/Medline, EMBASE/OVID SP, Cochrane CENTRAL and ClinicalTrials.gov) to identify relevant studies regarding pre-operative evaluation in geriatric patients undergoing surgery. A Boolean technique was used to build and implement an electronic database search strategy that included specified keywords, MeSH terms and text phrases deployed across relevant electronic databases. Frailty and surgery, nutrition status, pre-operative assessment, post-operative outcome and surgery (hip or general) were utilised as search terms and phrases, with particular inclusion and exclusion criteria employed.

The search criteria were human studies published in English and age (65 years or older). Abstracts were screened for randomised controlled trials with a defined assessment methodology relevant to this review's scope using pre-defined criteria. Full-text articles were reviewed, and 'backward' bibliography searches and 'forward citation reviews' were performed to identify any studies not found in the initial searches. A similar strategy was used to find published evidence summaries in systematic reviews on the subject. These were screened to ensure that relevant literature was identified and reported findings from individual meta-analyses were reviewed. The most recent revisions to pertinent published guidelines and best practice recommendations were reviewed. With the help of a research librarian, a search strategy was put together that covered the time period from 1990 to the present. The most recent search was conducted in December 2021.


  Geriatric Appraisal Of The Elderly Surgical Patient Top


To achieve the ideal surgical outcomes in elderly patients, thorough pre-operative evaluation and management of concomitant comorbidities are essential. Conventionally, age and pre-existing medical comorbidities have been utilised to determine the risk of surgical outcomes in older people.[8],[9] For older patients to get the best care possible, surgical datasets should include more information about how they think, make decisions, move and function.[10]


  Function and Mobility Top


Geriatric patients are a diverse group and have varied functional statuses. Poor surgical outcomes have been linked to low functional status, which may be a more reliable predictor of adverse events than cardiac risk assessment. In individuals who do not frequently exercise, assessing daily activities' metabolic equivalents (METs) is an excellent technique to estimate exercise tolerance. Surgery's metabolic demands are around 4 METs of physiologic stress. As a result, measuring function before surgery in older surgical patients is crucial for risk categorisation and post-discharge planning. Inquiring about a history of falls, assessing fall risk and doing the Timed-Up-and-Go test are all effective ways to assess mobility impairment.[11] The Timed-Up-And-Go test requires patients to complete the necessary tasks in the following order:

  1. Stand up from a chair (without using armrests if possible)
  2. Walk 10 feet
  3. Turn around and walk back to the chair
  4. Sit down in the chair.[11]



  Cognition Top


Poor sensorium has been associated with an increased risk of surgical complications and mortality, making delirium, dementia and depression essential considerations when evaluating cognition. Patients with pre-existing cognitive impairment are more likely to experience post-operative delirium (POD), which is related to prolonged hospital stays and higher mortality. Consequently, there is an increased risk of post-operative complications such as pneumonia, deep vein thrombosis, stroke and cerebrovascular accidents with neurologic impairment in patients with impaired cognition.[12]

The current ACS-AGS guidelines for adequate pre-operative assessment of the older patient include a standard pre-operative neurocognitive assessment. The Mini-Cog test is a convenient tool for screening pre-operative cognitive impairment in patients without a known history of cognitive impairment. It consists of a three-item memory test and a clock drawing test.[13],[14] It is a cognitive 'vital signs' tool used to screen multilingual elderly people for dementia. The test is recommended as a quick, easy-to-use, well-researched tool for predicting post-operative problems such as POD or post-operative cognitive impairment. The Mini-Cog has a high sensitivity for detecting moderate neurocognitive problems and is unaffected by the patient's educational background. This handy tool may be appropriate for use in clinical practice.[15],[16]

As part of the physical examination, cognition should initially be evaluated informally; simple questions concerning orientation to self, place and time and asking a patient to recall and explain a recent experience are sufficient (e.g. upcoming surgery). In addition, it can be used to evaluate short-term memory. The Mini-Cog is the most practical cognitive evaluation instrument for non-geriatricians since it is simple to administer and is not influenced by language or education.[6],[17]


  Delirium Top


The POD presents as a common surgical complication with an incidence of 11.6%–17.7%.[18],[19] A history of stroke, the use of hypnotics that do not contain benzodiazepines, hyponatremia before surgery, the prognosis nutritional index and the SF-36 physical component summary score are all things that were reported to predict delirium in older patients who underwent spine surgery.[19] The most vulnerable high-risk group of patients are those with pre-existing dementia and those over the age of 75 years.[18] Therefore, an anaesthesiologist and a geriatrician should be part of a team that takes care of patients before and after surgery to avoid and treat post-operative complications.


  Nutrition Top


Malnutrition is prevalent in the geriatric population, with an incidence of 38.7% in the elderly who are hospitalised.[20] Malnutrition can manifest itself in various ways, including reduced food intake, involuntary weight loss, an abnormal body mass index (BMI), low albumin and vitamin deficiencies. One of the characteristics of the frailty syndrome is weight loss. A complete evaluation might be considered for patients undergoing major surgical procedures, and the brief version of the Mini Nutritional Assessment can be used.[21] The National Surgical Quality Improvement Program (NSQIP) of the ACSs and the AGSs Best Practice Guidelines advocate noting the following in elderly patients: (a) height, weight and BMI; (b) serum albumin and pre-albumin concentrations at baseline. Inquire about any unintended weight reduction in the past 6 months.[6],[22]

Patients at high nutritional risk should have a perioperative nutritional plan prepared by a dietician, and as part of that plan, they should take multivitamins and nutritional supplements. Defining malnutrition in the elderly is a challenging task. Infection, disorientation, poor wound healing, muscular weakness leading to falls and fractures and prolonged intubation may all be a fallout of malnutrition. It has also been linked to an increased length of stay, readmission rates and mortality rates.[23]


  Frailty Top


Age-related conditions such as frailty have been linked to poor post-operative outcomes.[24],[25] Physical frailty and a composite phenotype, which includes aspects of the psychological, social and cognitive domains, manifest this dynamic process.[26] New research is focusing on 'prehabilitation' to improve functional status before elective surgery and reduce the post-operative length of stay and complications.[27] Frailty can be diagnosed using a variety of methods and instruments.[28] Frailty was defined as a proportion of accumulated deficits by Rockwood et al., who used a multidomain approach (impaired continence, walking, cognition and activity of daily living disability).[29] The term 'frailty' has been used to describe a vulnerability in at least two domains, including physical and nutritional, cognitive and sensory, whereas others suggest that gait speed or handgrip strength alone is the most reliable indicator of frailty.[30],[31] Identifying frailty may help determine which elderly patients are at risk for poor surgical outcomes. One evidence-based protocol includes five characteristics: subjective report of exhaustion, low physical activity, objective tests of grip strength and walking speed and accidental weight loss, where 3 of 5 are deemed diagnostic of frailty, and 2 of 5 are considered pre-frailty.[32]


  Pre-Operative Evaluation Of Comorbid States Top


The cardiovascular health of elderly patients should be evaluated as a top priority. The American College of Cardiology/American Heart Association publishes guidelines for assessing cardiac risk that takes both vascular and renal factors into account. Lee's Revised Cardiac Risk Index and new beta-blocker treatment guidelines have also been published.[33],[34] New guidelines for pre-operative pulmonary assessment have also recently been established. Furthermore, all of the patient's medical issues, including diabetes and thyroid status, must be addressed to limit post-operative complications.[33],[34]


  Additional Considerations Top


Undiagnosed problems in the elderly include depression, substance abuse, anxiety and social isolation. These possible impediments to healing, safe discharge following surgery and independence can be recognised through diligent screening.

Individuals 82 years and older are highly susceptible to anxiety. Late-life anxiety is associated with depression, impaired cognition and recent loss.[35] Depression and cognitive disorders are less common than sub-syndromal anxiety. As a result, anxiety is widespread among the elderly, and it is one of the most common geriatric disorders. Anxiety disorders, fortunately, can be treated with prescription medications and therapy.

According to a study from India, around 33% of the senior population suffers from depression, with women accounting for the bulk of those affected.[36] A simple two-question screening tool for depression is the patient health questionnaire-2.[37]

  1. 'In the past 12 months, have you ever had a time when you felt sad, blue, depressed or down for most of the time for at least 2 weeks?'
  2. 'In the past 12 months, have you ever had a time, lasting at least 2 weeks, when you did not care about the things you usually care about or when you did not enjoy the things you usually enjoy?'


The elderly also are susceptible to substance abuse, such as alcohol consumption. 13% of men and 8% of women over 65 consume at least two alcoholic beverages per day.[38]


  Decision-Making Capacity Assessment Top


Decision-making capacity and competency are impaired in elderly patients.[39] The health-care team, the patient's family and caregivers should all be aware of and document the patient's goal and treatment choices. Patients with poor cognition should have surrogate decision-makers assigned to them. Preventing functional decline and delirium, early multispecialty consultation, early participation of allied health professionals such as physical or occupational therapy, and anticipating post-operative home health requirements can all be carried out. The decision-making capacity assessment focuses on non-operative solutions and patient-centred outcomes, including functional and living situations, instead of standard morbidity and mortality outcomes.


  Antibiotic Prophylaxis Top


Pre-operative antibiotics should be given 60 min before surgery, depending on the procedure, risk factors and hospital pathogen profile.[40] Patients over 65 may have impaired renal function, necessitating extra caution regarding drug dosing. However, in terms of indication or performance, there are no significant differences between perioperative antibiotic prophylaxis in the elderly and younger patients.[26]


  Venous Thromboembolism Prophylaxis Top


The risk of venous thromboembolism (VTE) increases with age. A structured approach should stratify these patients for VTE and bleeding risk. A VTE preventive strategy should be developed based on the patient's risk profile as suggested by the American College of Clinical Pharmacy and the ACS NSQIP Best Practices Guidelines.[41],[42]


  Medication Management Top


In order to optimise pre-operative assessment of older surgical patients, an ACS/AGS Best Practices Guideline has been published.[6],[43],[44] In addition, medication lists should be examined for unneeded or unsuitable drugs.


  Pre-Operative Fasting Top


For non-emergent surgical procedures, geriatric patients should fast per standard fasting guidelines for adults. Unnecessary fasting worsens post-operative agitation and confusion in elderly patients prone to dehydration.[45]


  Difficulty In Swallowing Top


Older adults should be screened for abnormal swallowing before elective surgery because they are at risk of aspiration pneumonia in the post-operative period.[46] If the test is positive, the patients should be assessed by a speech therapist before surgery, and a post-operative plan for restarting oral intake should be documented. Furthermore, the anaesthesia team should be informed of the potential for aspiration before surgery and the care team postoperatively. Before restarting oral intake, elderly adults should be assessed for swallowing problems in a non-elective environment. If the screening is positive, the patient should contact a speech therapist who will devise a strategy for resuming oral intake.[47],[48],[49]


  Need For a Palliative Care Assessment Top


Geriatric palliative care combines hospital medicine and palliative care disciplines to provide comprehensive, whole-person care to elderly patients with serious illnesses.[50] Within a year of sustaining a severe traumatic brain injury, more than 80% of older patients die or become severely disabled.[51] People with cancer have traditionally received palliative care, but people aged 85 and up are more likely to die of cardiovascular disease than cancer. In order to better meet the needs of older people in the future, palliative care must be improved and expanded to include people dying from diseases other than cancer and those who have multiple illnesses. Multiple debilitating diseases, such as dementia, osteoporosis and arthritis, are common in older people nearing the end of their lives, and they often last longer. Dementia, for example, affects one-quarter of people aged 85 and up.[52],[53]


  Investigations Top


Several guidelines, including those developed by the American Society of Anesthesiologists (ASA), the National Institute for Health and Care Excellence (NICE), the ACS and the AGS, have been developed for pre-operative evaluation, including laboratory investigations.[6],[7],[54] In the early 2000s, NICE guidelines were applied to people over 16. The ACS and AGS later developed guidelines for geriatric patients. Pre-operative testing should be guided by a focused history and physical examination, known comorbidities and surgical technique. The ACS NSQIP®/AGS recommends haemoglobin, serum albumin and renal function tests (blood urea nitrogen, serum creatinine) for all geriatric patients. White blood cell count, platelet count, coagulation test, electrolytes, serum glucose, urinalysis, chest radiograph, electrocardiograms (ECGs), pulmonary function tests and non-invasive stress tests are not recommended for routine pre-operative screening but may be required for certain geriatric surgical patients.[6]

The NICE Guidelines (2016) may be used for patients over the age of 16 years including adults and young people undergoing any surgical procedure. The pre-operative investigations are based on ASA grade and surgical categories (minor, intermediate, major and complex). Routine and lung function tests are not required for patients with ASA statuses I and II, but kidney function tests and an ECG are essential for patients with ASA statuses III and IV. Patients with ASA status II undergoing intermediate surgery should have kidney function tests and an ECG, whereas patients with ASA III or IV should only have liver function tests/arterial blood gas. Patients with any ASA status undergoing major or complex surgeries are given a complete blood count, kidney function tests and an ECG. For ASA status I, haemostasis and liver function tests are not routinely performed. For patients with an ASA of III or IV, however, all of these tests may be considered.[54]

The NICE guidelines cover the following tests: complete blood count (haemoglobin, white blood cell and platelet count), haemostasis, renal function (estimated glomerular filtration rate, electrolytes, creatinine and occasionally urea values) and lung function (spirometry, including peak expiratory flow). Before surgery, chest X-rays, ECGs and echocardiography are not routinely performed. In some cases, resting echocardiography is considered. The guideline committee has recommended polysomnography and glycated haemoglobin testing for patients with OSA and diabetes mellitus, respectively.

There are various tests for pre-operative evaluation of the geriatric population. They should be used selectively as follows:

  1. Haemoglobin: All elderly individuals, especially those over the age of 80 years, should have their haemoglobin levels evaluated, also those with a history of extreme fatigue, anaemia or malignancy and those undergoing surgery that may result in significant blood loss needing a transfusion. Haemoglobin should also be checked in patients with conjunctival pallor or resting tachycardia.
  2. Serum albumin: Geriatric pre-operative patients with malnutrition, known liver disease, several significant chronic or recent diseases or who are having major surgery should undergo this test.
  3. White blood cell counts must be evaluated in patients with an infection, myeloproliferative illness or at high risk of drug-induced leucopenia or other conditions.
  4. Platelet count is mandatory in patients at risk of developing thrombocytopenia or thrombocytosis.
  5. Coagulation tests: Geriatric patients who have a history of bleeding or clotting disorders, are on anticoagulants and or on dialysis, are malnourished or have liver disease should have these tests (prothrombin time, partial thromboplastin and international normalised ratio) done before heart or vascular surgery, cancer surgery, neurosurgery, orthopaedics or other procedures in which even a minor amount of bleeding can be dangerous, such as dialysis or kidney transplants.
  6. Renal function tests are advised for all elderly patients, especially those undertaking major surgery (cardiac, vascular, chest or abdominal), having diabetes, hypertension or taking drugs that affect renal function, such as angiotensin-converting enzyme (ACE) inhibitors and non-steroidal anti-inflammatory drugs.
  7. Serum electrolytes should be evaluated in patients suffering from congestive heart failure, renal insufficiency and taking medications that can impact electrolyte levels such as ACE inhibitors, digoxin, diuretics and the like.
  8. Serum glucose should be checked in patients with known or suspected diabetes or those who are obese.
  9. Urine analysis should be performed on patients who have a suspected urinary tract infection, are posted for urogenital surgery, or have diabetes.
  10. Chest radiographs should not be performed routinely before surgery but are recommended in patients with suspected acute cardiopulmonary disease, especially those with chronic obstructive pulmonary disease (COPD), asthmatics and smokers. It should also be done on individuals over 70 with a stable chronic cardiopulmonary illness history and no previous chest radiographs in the past 6 months. Thyroidectomy, abdominal, oesophageal, various head and neck, neurosurgery or lymph node surgeries may need a baseline chest X-ray in patients requiring critical care.[55]
  11. ECGs: Routine pre-operative ECGs are not recommended in asymptomatic patients, especially those undergoing low-risk procedures. It is mandatory in those patients listed for intermediate-risk or vascular surgery, or a history of cardiac arrhythmias or myocardial infarction in the past, compensated or prior heart failure, suffer from ischemic heart disease, cerebrovascular disease, respiratory or renal impairment and peripheral vascular disease. Age-based criteria in otherwise healthy persons have inconsistent data, although presumably appropriate if a low-risk operation is not done.[25],[56]


Are we over-investigating geriatric patients? The answer is no. The ground reality is the reverse, particularly in the Indian context. Even in metropolitan regions, most individuals do not receive preventative health examinations. We need to do much more, especially in evaluating the geriatric patients regarding communications about consent, any advanced directives (Do not intubate, Do not resuscitate), cognitive function and functional mobility. At times, we are liberal in getting chest X-rays and resting echocardiography, but then our patients seldom have regular follow-ups, and cardiorespiratory assessment is complex due to trauma, frailty, or reduced mobility. The incidence of malnutrition, infection (tuberculosis), hypertension and diabetes mellitus is high in the Indian scenario.

In conclusion, pre-operative assessment in elderly frail patients with multiple comorbidities can be challenging and time-consuming. Therefore, it is mandatory to correct inadequacies or deficiencies as much as possible before surgery if the best surgical results, safety and outcomes in this population are to be achieved. However, a comprehensive geriatric assessment guided and supported by the latest evidence can help achieve safe and optimum surgical outcomes.

Acknowledgements

The authors would like to thank Ms. Priya Yadav, our research officer, and our secretary, Mr. Prakash for their help in the preparation of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
Methods
Geriatric Apprai...
Function and Mob...
Cognition
Delirium
Nutrition
Frailty
Pre-Operative Ev...
Additional Consi...
Decision-Making ...
Antibiotic Proph...
Venous Thromboem...
Medication Manag...
Pre-Operative Fa...
Difficulty In Sw...
Need For a Palli...
Investigations
References

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